Laparoscopic parastomal hernia repair using a keyhole technique results in a high recurrence rate

Laparoscopic parastomal hernia repair: keyhole, Sugarbaker, sandwich, or hybrid technique with 3D mesh? An updated systematic review and meta-analysis

PURPOSE

Parastomal hernia is the most common complication after stoma formation with an incidence that approaches 50% at 2 years postoperatively. In the last decade, different approaches of minimally invasive procedures have been proposed for the treatment of parastomal hernia. Nevertheless, the superiority of one technique over the others remains still unclear. Our objective was to update and systematically analyze current state of research concerning the postoperative outcomes of the four most prevalent minimally invasive techniques.

METHODS

A systematic literature search of three databases (Medline, Scopus, Google Scholar) was undertaken for articles published from January 2015 to November 2022. Fifteen studies from a previous meta-analysis on the topic were included.

RESULTS

Thirty-three studies incorporating 1289 total patients were deemed eligible for inclusion in the final analysis. The keyhole technique was associated with the highest incidence of postoperative complications and recurrences (31.3% and 24.1%, respectively), followed by the Sugarbaker technique (27.6% and 9%, respectively). Operative time was among the lowest in patients operated with the 3D mesh technique, while patients undergoing the keyhole technique experienced the shortest cumulative length of hospital stay (6 days).

CONCLUSION

Each technique demonstrates a unique profile of effectiveness offset by the propensity towards developing postoperative complications. While no conclusive evidence on the optimal technique exist to date, newer minimally invasive techniques show promising results, albeit based on limited data. The future of parastomal hernia repair seems to rely on a highly individualized approach, tailored to the distinctive characteristics of both the hernia and the patient.

Spontaneous Resolution of Parastomal Gallbladder Herniation After Attempted Surgical Intervention: A Case Report and Review of the Literature

Cholecystic parastomal herniation is a rare condition that has only been documented 16 times in the literature. We present a case report and literature review of cholecystic parastomal herniation managed with diagnostic laparoscopy without cholecystectomy or hernia repair. Furthermore, we assess the demographics, presentation, stoma types, and management of cholecystic parastomal hernias across all documented cases.

Surgical strategies for recurrent parastomal hernia after a primary repair with a Dynamesh® IPST mesh

PURPOSE

To introduce our surgical strategies for recurrent parastomal hernia after a primary repair with a Dynamesh^® IPST mesh.

METHODS

Ten patients who underwent recurrent parastomal hernia repair with previous Dynamesh^® IPST mesh use were analyzed retrospectively. Distinct surgery strategies were applied. Accordingly, we investigated the recurrence rate and postoperative complications in these patients, who were followed for an average of 35.9 months after surgery.

RESULTS

There was no recorded death and no readmission during the 30-day postoperative period. And the lap-re-do Sugarbaker group had no recurrence, whereas the open suture group had one recurrence (16.7%). One patient in the Sugarbaker group developed ileus and recovered conservatively during the follow-up period. There were no other complications, including seroma, mesh infection and bulging, or prolonged postoperative pain.

CONCLUSIONS

We offer two predominant surgery strategies for recurrent parastomal hernia with a previous Dynamesh^® IPST mesh usage, the open suture repair, and the Lap-re-do Sugarbaker repair. Even though the results of the Lap-re-do Sugarbaker repair are satisfactory, we recommend the open suture technique as it is safer in a setting of dense adhesions in recurrent parastomal hernias.

Sugarbaker Versus Keyhole Repair for Parastomal Hernia: a Systematic Review and Meta-analysis of Comparative Studies

INTRODUCTION

Parastomal hernia is a debilitating complication of stoma creation. Parastomal hernia repair with mesh reduces recurrence rates in open and laparoscopic settings. Recent comparative studies conflict with previously pooled data on optimal mesh repair technique. The objective of this study is to examine parastomal hernia recurrence rates after Sugarbaker and keyhole repairs by performing an updated systematic review and meta-analysis of comparative studies.

METHODS

A systematic review of PubMed, MEDLINE, EMBASE, the Cochrane database, SCOPUS, and the PROSPERO registry was performed according to PRISMA 2020 guidelines (PROSPERO ID: CRD42021290483). Studies comparing parastomal hernia recurrences after Sugarbaker and keyhole repairs were included. Studies with overlapping patient cohorts (duplicate data), non-comparative studies, studies that did not report the primary outcome of interest, and studies not in the English language were excluded. Study bias was assessed using the Newcastle-Ottawa scale. Pooled mean differences (MD), odds ratios (OR), and risk ratios (RR) with 95% confidence intervals (CI) were calculated. Heterogeneity was assessed using the I² statistic. Forest plots and funnel plots were generated. Study quality was analyzed using MINORS. Additional subgroup analysis of modern studies was performed.

RESULTS

Ten comparative studies published between 2005 and 2021 from 5 countries were included for analysis comprising 347 Sugarbaker repairs and 246 keyhole repairs. There were no differences in patient age, sex, or BMI between the groups. There was no difference between the groups regarding surgical site infection (OR 0.78; CI 0.31-1.98; P = 0.61) or post-operative bowel obstruction (OR 0.76; CI 0.23-2.56; P = 0.66). Sugarbaker repairs were significantly less often associated with parastomal hernia recurrence when compared to keyhole repairs (OR 0.38; CI 0.18-0.78; P = 0.008). There was no significant heterogeneity among the studies comparing parastomal hernia recurrence (I² = 32%; P = 0.15). Quality analysis revealed a median MINORS score of 11 (range 6-16). Subgroup analysis of studies performed after the previously published pooled analysis (2015-2021) revealed no significant difference in parastomal hernia recurrence between the two groups (OR 0.58; CI 0.24-1.38; P = 0.22) with a significant subgroup effect (P = 0.05).

CONCLUSIONS

Though there were lower rates of parastomal hernia recurrence with Sugarbaker repairs on overall analysis, this phenomenon disappeared on subgroup analysis of modern studies. Randomized controlled trials with contemporary cohorts would help further evaluate these repairs and minimize potential bias.

Feasibility of using a tailored mesh in laparoscopic Sugarbaker parastomal hernia repair

BACKGROUND

In parastomal hernia (PH) repair, laparoscopic Sugarbaker technique (LS) is considered the best practice; however, meshes specific for LS repairs ceased to be available.

PURPOSE

The aim of the study was to evaluate feasibility of using a physician-modified mesh (tailored mesh: TM) in LS.

METHODS

Thirty-three patients who underwent LS for PH between June 2012 and September 2021 were examined to compare surgical outcomes between LS with TM (n = 11) and with a ready-made specific mesh (SM, n = 22). All meshes were coated plastic meshes. Statistical analysis was performed with the Mann-Whitney U test and Fisher's exact test. P < .05 was considered to be statistically significant.

RESULTS

We compared the outcomes of TM with SM in LS for similar hernia types during median follow-up periods of 23 (range, 2-29) and 74 (range, 36-110) months (P < .0001), respectively. The median operation times were 146 (range, 45-423) for TM and 193 (range, 65-386) minutes for SM (P = .2301). Perioperative complications were observed in one TM patient (9%) and two SM patients (9%) (P = 1.0000). The lengths of postoperative stay were similar. Recurrence was observed in two cases in the SM group (9%) within 1 year after the operation.

CONCLUSION

In LS, TM seems to be a feasible mesh comparable to SM within short- and mid-term follow-up.

A keyhole approach gives a sound repair for ileal conduit parastomal hernia

PURPOSE

The purpose of this study was to report and evaluate a laparoscopic surgical technique for the treatment of parastomal hernia (PSH) after ileal conduit urinary diversion aiming to minimize PSH recurrence and perioperative complications.

METHODS

We retrospectively evaluated all patients who underwent a PSH (after ileal conduit urinary diversion) repair at Addenbrookes Hospital, Cambridge. As a surgical approach, a laparoscopic repair with mesh was utilized in all cases. Subsequently, we performed a voluntary follow-up of the patients to evaluate long-term recurrence and complication rates. In addition, we conducted a reassessment of the cross-sectional imaging available.

RESULTS

Between November 2008 and December 2019, 27 patients underwent hernia repair due to a clinically significant hernia. Out of those patients, one suffered from a post-operative wound infection. In total 23 patients participated in the follow-up with a median follow-up period of 91 months. Follow-up examination revealed two cases of recurrent PSH (8.7% of patients followed up), four patients suffered from minor complications (14.8%).

CONCLUSION

Repair of PSH associated with ileal conduit is particularly scarce. Our surgical approach presents the only laparoscopic case series of an effective method for treating a PSH from an ileal conduit with a low complication and recurrence rate.

Modified Laparoscopic Sugarbaker Repair of Parastomal Hernia With a Totally Extraperitoneal Technique

Purpose: Many patients develop a parastomal hernia within the first 2 years of stoma formation, and even surgical repair is associated with high recurrence rates. An intraperitoneal approach is typically used for the laparoscopic repair of parastomal hernia; it is unknown whether a totally extraperitoneal technique (TEP) is feasible. Here we describe a laparoscopic TEP approach using a modified Sugarbaker method for the repair of parastomal hernia.

Methods: Seven patients underwent parastomal hernia repair. The retrograde puncture technique was used to create the extrapneumoperitoneum, and the peritoneum was separated with a laparoscopic TEP approach; the mesh was placed using a modified Sugarbaker technique.

Results: All patients had an oncologic etiology for stoma creation. The mean (±SD) size of the hernia defect was 3.1 ± 2.7 cm and the mesh size was 303.4 ± 96.8 cm². The mean operative time was 195.5 ± 20.7 min and average length of hospital stay after surgery was 4.8 ± 2.1 days. One patient had intraoperative subcutaneous emphysema. The average follow-up time was 8.5 ± 2.7 months; mild pain occurred in 2 patients, 3 experienced seroma formation (with no special treatment required), and 1 had early intestinal obstruction (which was treated with conservative care). There was no hernia recurrence, wound complications, or infections of the surgical site or mesh during follow-up.

Conclusion: A laparoscopic TEP technique is technically challenging but feasible. Modified laparoscopic Sugarbaker repair of a parastomal hernia with the TEP technique is safe and effective, although the recurrence rate and late complications require confirmation in more cases with long-term follow-up.

Prophylactic mesh placement at index permanent end colostomy creation to prevent parastomal hernia-an updated meta-analysis

BACKGROUND

Debate persists regarding the efficacy of prophylactic mesh insertion (PMI) at index permanent stoma creation to reduce the rate of parastomal hernia (PSH). This meta-analysis aimed to appraise all the latest evidence from newly published randomized controlled trials (RCTs) on PMI for PSH prevention.

METHODS

PubMed, EMBASE, and Cochrane databases were searched for relevant articles from inception until November 2020. All RCTs that reported on PMI at end colostomy creation with ≥ 12 months follow-up were included. The primary objective was the rate of clinical and radiological PSH while secondary objectives included number of PSH requiring repair and stoma (or mesh)-related complications. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed.

RESULTS

Eleven RCTs were included capturing 1097 patients. The mean (SD) age was 67.9 (±9.4) years. On random effects analysis, prophylactic mesh appeared to reduce the rate of both clinical (OR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and radiological (OR = 0.39, 95% CI = 0.24 to 0.65, p = 0.0002) PSH. However, there was no difference in number of PSH requiring repair or stoma-related complications. On sensitivity analysis, when focusing on low-risk of bias studies, the benefit of prophylactic mesh in the retrorectus space was lost for both clinical (OR = 0.97, 95% CI = 0.62 to 1.51, p = 0.89) and radiological PSH (OR = 0.74, 95% CI = 0.46 to 1.18, p = 0.20).

CONCLUSION

PMI may reduce the rate of subsequent PSH. However, further studies are required to confirm these findings and to establish the optimal mesh position and shape before definite recommendations can be made.

Preoperative Progressive Pneumoperitoneum and Botulinum Toxin Type A in Patients With Large Parastomal Hernia

Background: The combination of preoperative progressive pneumoperitoneum (PPP) and botulinum toxin type A (BTA) in adjuvant treatment of large parastomal hernia (LPH) has not been reported in the previous literature.

Methods: From February 2018 to June 2019, 16 patients were diagnosed with LPH in our hospital were included in this study. All patients received PPP and BTA treatment to expand abdominal volume and extend abdominal muscle before surgery. The laparoscopic Sugarbaker method was preferred for defect close.

Results: Before and after PPP and BTA, the mean volume of the parastomal hernia (VPH) was 1,522 and 1,644 cc, respectively (P < 0.01), and the mean volume of the abdominal cavity (VAC) was 5,847 and 9,408 cc, respectively (P < 0.01). The VPH/VAC ratio was decreased by an average of 8.4% after the combination management. And the lateral abdominal muscle length was increased by an average of 4.8 cm/side (P < 0.01). These patients underwent surgery successfully, and no hernia recurrence after (17.6 ± 2.4) months of follow-up.

Conclusions: The combination of PPP and BTA effectively expand the abdominal volume, decrease the risk of abdominal compartment syndrome (ACS) postoperatively, and beneficial to laparoscopic repair of LPH.

Endoscopic Totally Extraperitoneal Repair of Parastomal Hernia: A Case Report

A parastomal hernia is a type of incisional hernia that occurs in abdominal integuments in the proximity of a stoma. It is a frequent late complication following colostomy. Surgical repair is currently the only treatment option for parastomal hernia. Here we present the case of a 74-year-old patient with parastomal hernia and a history of open surgery treated with a totally extraperitoneal (TEP) endoscopic approach. There was no recurrence of the hernia at the 3-month follow-up. We discuss the feasibility and possible operative approaches for endoscopic repair of parastomal hernia with the TEP technique.

A new anterior approach to parastomal hernia repair (PHR) with linear stapler suture: A case report

Introduction

Parastomal hernia is a type of incisional hernia occurring in abdominal integuments in the vicinity of a stoma. The best surgical approach for PSH remains controversial. Most studies report short follow-up time after surgery and a low number of cases to allow conclusions. Actually, we don't have a relevant recommendation about an optimal surgical technique or the most effective mesh for PSH repair.

Presentation of the case

Once packaged the latero-lateral mechanical anastomosis to restore the continuity of the intestinal tract of the patient, an adequate disinfection of trough of the stoma was done. The lateral and medial margins of the defect are then transposed towards each other and kept side by side with a gripper; a 60 mm tristaple linear stapler was placed, incorporating both edges and the charge is fired to obtain a perfect synthesis of the retromuscular plane.

Discussion

In the literature has been described several surgical techniques for its repair: suture repair, relocation, mesh-based technique with open or laparoscopic approach. Both, the simple corrective surgery of Thorlakson in 1965 and the use of the peritoneomuscular flap for closing the defect, suggested by Bewes, led to high incidence of recurrence. An important reduction in the rate of parastomal hernia derives also from the mesh reinforcement of the stoma trephine.

Conclusion

The authors suggest that this technique should be help the surgeons to repair parastomal hernia in patients with multiple risk factors to develop a recurrence of parastomal hernia.

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The best surgical approach for Parastomal Hernia repair (PSH) remains controversial.

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Causes that predispose to the development of incisional hernia are multiple, such as obesity and diabetes.

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This technique may help the surgeons to repair the PSH in patients with risk factors to develop a recurrence after surgery.

From keyhole to sandwich: change in laparoscopic repair of parastomal hernias at a single centre

BACKGROUND

Nearly 50% of patients with an ostomy will develop a parastomal hernia (PSH). Its repair remains a surgical challenge. Both laparoscopic "modified Sugarbaker" (SB) and Keyhole (KH) repair are currently in use, frequently with unsatisfactory results.''Sandwich Repair'' (SR) may be an alternative to reduce recurrence rates. We present the change of our technique from KH to SR.

METHODS

We collected data from all consecutive laparoscopic PSH repairs at our institution from 2004 until now (from 2004 to 2013 treated with KH, from 2014 with SR) and compared the results of the two groups. Primary endpoint was recurrence rate at 1 year. Secondary outcomes were operative time, PO length of hospital stay (LOS), and short and long-term complications.

RESULTS

13 patients underwent SR. Main changes in surgical technique concerned primary defect closure, no stay sutures, use of glue for first mesh fixation, and partial lateral covering of the underlying mesh with a peritoneal flap. Early postoperative course after SR was uneventful and no recurrence at 1 year was recorded. In the KH group (19 patients), short-term complications occurred in two cases (10%), with one parietal hematoma and one case of intensive pain; we had four recurrences at 1 year (21%). LOS was shorter in the SR group (mean 4 days vs 6, p = 0.004). The KH group had 2 (10%) occurrences of chronic seroma and one bowel perforation (5%), while the SR group had one (8%) occurrence of chronic pain. Median follow-up was 26 months (range 13-78) for the SR group and 47 months (12-105) for the KH group.

CONCLUSION

SR is safe and effective in expert hands and provides promising preliminary results.

[Principles and parallels of prevention and repair of parastomal hernia with meshes]

After formation of a permanent terminal stoma by enterostomy, parastomal hernia (PSH) occurs in up to 80% of cases and leads to a wide variety of symptoms and complications with a high rate of emergency operations due to incarceration (ca. 15%). Consequently, greater consideration should be given to PSH prevention even as early as the time of enterostomy and generously applied indications for elective repair of manifest PSH. The aim of this article is to summarize and evaluate the current evidence for PSH repair and prevention. Poor postoperative results after attempted repair of manifest PSH with slit meshes in different layers of the abdominal wall shift the focus onto stoma lateralization (sandwich and Sugarbaker techniques) or 3‑dimensional tunnel-shaped implants with meshes to cover the stomal edges. To date, the best strategy for PSH prevention has still not been defined and techniques with slit meshes show different results. Nevertheless, 10 prospective randomized trials, meta-analyses, a Cochrane review and guidelines from the European Hernia Society (EHS) about various slit-mesh devices in sublay, onlay and intraperitoneal positions confirmed significantly reduced rates of PSH after mesh augmentation compared to conventionally sutured enterostomy without morbidity associated with the implanted material. Despite the positive data situation PSH prevention is seldom performed in daily practice, which is due to uncertainty surrounding the most suitable surgical strategy, the necessity to spend additional time at the end of a demanding operation, the aversion to implanting meshes into a contaminated operative field and the lack of remuneration of preventive surgical procedures. Future trials should, therefore, no longer compare standard enterostomy techniques with one prevention method in general but should have a new focus on techniques providing adequate results in PSH repair (Sugarbaker, sandwich and 3‑D tunnel meshes), probe the advantages and evaluate the differences in outcome between these strategies.

Laparoscopic Modified Keyhole Technique with Coated Polyester Mesh for Treatment of Parastomal Hernia: Measures for Improving the Outcome

Purpose: Although the modified Sugarbaker technique gives good results for the treatment of parastomal hernia (PH), there are other valid options for the treatment of this frequent complication. In our practice, the laparoscopic keyhole (KH) technique, with some specific modifications, can give similar results. Materials and Methods: We collected data on all the patients with symptomatic PHs who underwent surgical repair between January 2002 and December 2017 in our surgical department. The primary endpoint was to evaluate the recurrence rate after at least 1 year, determined on the basis of physical examination during follow-up and on postprocedure radiological results. Results: Ninety patients were treated with the KH technique. The stomas that were treated were 83 end colostomies and 7 ileal ureterostomies. Eighty-eight patients were treated with polyester mesh (Parietex™, Medtronic, Ireland) and 2 with a composite mesh (Physiomesh™, Ethicon). Patients had median follow-up period of 1 year. Seroma occurred in 4 patients, who were treated conservatively by clinical monitoring. Four patients had a recurrence: 1 occurred on the seventh postoperative day, due to a technical error; 1 after 6 months, due to the partial shrinkage of the mesh into the defect; the third after 1 year, but it occurred at the beginning of our experience, and the last recurrence was after 3 years in a patient who gained 15 kg after the procedure. Conclusions: If a few precautionary steps are added to the original technique, laparoscopic KH repair is feasible and safe, giving good results in terms of complications and recurrence rates.

Laparoscopic parastomal hernia repair: A modified technique of mesh placement in Sugarbaker procedure

Introduction

Conventional surgery for parastomal hernia entails primary suture repair or stoma relocation. Laparoscopic surgery has advantages of less pain, faster post-operative recovery and better cosmesis. While the Sugarbaker technique has been valued for least recurrences, however, it exposes the stomal loop to the parietal surface of the mesh exposing it to complications. We report a modification of mesh placement after primary defect repair to improvise the safety of meshplasty and to minimise mesh erosions into the stomal loop of bowel.

Patients and Methods

Patients with permanent stoma presenting with a parastomal bulge leading to difficulty with stoma care or abdominal distention or pain were included in the study. A pre-operative computed tomography scan was performed in all patients to rule out any recurrence of primary pathology for which stoma was created and to study the abdominal musculature and defects.

Results

Of 14 patients, 12 patients had end-sigmoid stoma, one had end ileostomy following surgery for ulcerative colitis and one had urinary conduit. The size of the defect varied from 4.5 cm to 6 cm in diameter, and the average duration of surgery was 125 min. Pain assessed on VAS score was higher in the first 12 h, and all were started on orals on the next day, and average hospital stay was 4.2 days. The longest follow-up of 7 years and shortest of 15 months did not reveal any complications as recurrence, seroma, mesh infections or erosions into the stoma.

Conclusion

Modified placement of composite mesh is safe and helps in minimising mesh-related complications of the Sugarbaker technique for parastomal hernias.

Modified laparoscopic Sugarbaker repair of parastomal hernia with a three-point anchoring technique

AIM

To retrospectively evaluate the safety and feasibility of a new modified laparoscopic Sugarbaker repair in patients with parastomal hernias.

METHODS

A retrospective study was performed to analyze eight patients who underwent parastomal hernia repair between June 2016 and January 2018. All of these patients received modified laparoscopic Sugarbaker hernia repair treatment. This modified technique included an innovative three-point anchoring and complete suturing technique to fix the mesh. All procedures were performed by a skilled hernia surgeon. Demographic data and perioperative outcomes were collected to evaluate the safety and efficacy of this modified technique.

RESULTS

Of these eight patients, two had concomitant incisional hernias. All the hernias were repaired by the modified laparoscopic Sugarbaker technique with no conversion to laparotomy. Three patients had in-situ reconstruction of intestinal stoma. The median mesh size was 300 cm², and the mean operative time was 205.6 min. The mean postoperative hospitalization time was 10.4 d, with a median pain score of 1 (visual analog scale method) at postoperative day 1. Two patients developed postoperative complications. One patient had a pocket of effusion surrounding the biologic mesh, and one patient experienced an infection around the reconstructed stoma. Both patients recovered after conservative management. There was no recurrence during the follow-up period (6-22 mo, average 13 mo).

CONCLUSION

The modified laparoscopic Sugarbaker repair could fix the mesh reliably with mild postoperative pain and a low recurrence rate. The technique is safe and feasible for parastomal hernias.

Prosthetic mesh placement for the prevention of parastomal herniation

BACKGROUND

Parastomal herniation is a common problem following formation of a stoma after both elective and emergency abdominal surgery. Symptomatic hernias give rise to a significant amount of patient morbidity, and in some cases mortality, and therefore may necessitate surgical treatment to repair the hernial defect and/or re-site the stoma. In an effort to reduce this complication, recent research has focused on the application of a synthetic or biological mesh, inserted during stoma formation to help strengthen the abdominal wall.

OBJECTIVES

The primary objective was to evaluate whether mesh reinforcement during stoma formation reduces the incidence of parastomal herniation. Secondary objectives included the safety or potential harms or both of mesh placement in terms of stoma-related infections, mesh-related infections, patient-reported symptoms/postoperative quality of life, and re-hospitalisation/ambulatory visits.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2018, Issue 1), Ovid MEDLINE (1970 to 11 January 2018), Ovid Embase (1974 to 11 January 2018), and Science Citation Index Expanded (1970 to 11 January 2018). To identify ongoing studies, we also searched the metaRegister of Controlled Trials (mRCT) on 11 January 2018.

SELECTION CRITERIA

We considered for inclusion all randomised controlled trials (RCTs) of prosthetic mesh (including biological/composite mesh) placement versus a control group (no mesh) for the prevention of parastomal hernia.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies identified by the literature search for potential eligibility. We obtained the full articles for all studies that potentially met the inclusion criteria and included all those that met the criteria. Any differences in opinion between review authors were resolved by consensus. We pooled study data into a meta-analysis. We assessed heterogeneity by calculation of I² and expressed results for each variable as a risk ratio (RR) with corresponding 95% confidence intervals (CI). We expressed continous outcomes as mean difference (MD) with corresponding 95% CIs.

MAIN RESULTS

We included 10 RCTs involving a total of 844 participants. The primary outcome was overall incidence of parastomal herniation. Secondary outcomes were rate of reoperation at 12 months, operative time, postoperative length of hospital stay, stoma-related infections, mesh-related infections, quality of life, and rehospitalisation rate. We judged the risk of bias across all domains to be low in six trials. We judged four trials to have an overall high risk of bias.The overall incidence of parastomal hernia was less in participants receiving a prophylactic mesh compared to those who had a standard ostomy formation (RR 0.53, 95% CI 0.43 to 0.66; 10 studies, 771 participants; I² = 69%; low-quality evidence). In absolute numbers, the incidence of parastomal hernia was 22 per 100 participants (18 to 27) receiving prophylactic mesh compared to 41 per 100 participants having a standard ostomy formation.There were no differences in the need for reoperation (RR 0.90, 95% CI 0.50 to 1.64; 9 studies, 757 participants; I² = 0%; low-quality evidence); operative time (MD -6.50 (min), 95% CI -18.24 to 5.24; 6 studies, 671 participants; low-quality evidence); postoperative length of hospital stay (MD -0.95 (days), 95% CI -2.03 to 0.70; 4 studies, 500 participants; moderate-quality evidence); or stoma-related infections (RR 0.89, 95% CI 0.32 to 2.50; 6 studies, 472 participants; I² = 0%; low-quality evidence) between the two groups.We were unable to analyse mesh-related infections, quality of life, and rehospitalisation rate due to sparse data or because the outcome was not reported in the included studies.

AUTHORS' CONCLUSIONS

This Cochrane Review included 10 RCTs with a total of 844 participants. The review demonstrated a reduction in the incidence of parastomal hernia in people who had a prophylactic synthetic mesh placed at the time of the index operation compared to a standard ostomy formation. However, our confidence in this estimate is low due to the presence of a large degree of clinical heterogeneity, as well as high variability in follow-up duration and technique of parastomal herniation detection. We found the rate of stoma-related infection to be similar in both the intervention and control groups.

The modified laparoscopic keyhole parastomal hernia repair with in situ re-ostomy has low recurrence rate

PURPOSE

This study aimed to present a modified laparoscopic keyhole parastomal hernia repair technique with in situ re-ostomy and show its safety and feasibility at a mid-term follow-up.

METHODS

The technique begins with adhesiolysis during laparoscopy. An annular incision is made between the skin and stomal mucosa. Then, after all adhesions of the stomal bowel and its mesentery are separated from the hernial sac, the stomal bowel is delivered through the keyhole mesh. The mesh is then stitched to the stomal bowel and placed intraperitoneally. The hernial ring is narrowed, and the mesh is further stitched to the hernial ring and stomal tube. After the mesh is fixed, the redundant stomal bowel is shortened, and a new in situ stoma is matured in the conventional way.

RESULTS

Altogether, 65 consecutive patients underwent successful hernia repair via a modified laparoscopic keyhole with in situ re-ostomy. Two of the patients had recurrent parastomal hernias. No mortalities occurred during the perioperative period. Morbidities included two cases of seroma and three of ileus, all of which were cured with conservative treatment. In addition, one case of intestinal perforation was rescued by intestinal resection and enteroenterostomy. Median follow-up was 29 months (range 3-60 months). No complications of mesh-related infection or patch erosion were noted during the follow-up.

CONCLUSIONS

Modified laparoscopic keyhole parastomal hernia repair with in situ re-ostomy is a safe procedure with a low recurrence rate at the mid-term follow-up.

Laparoscopic repair for parastomal hernia with ongoing barbed suture followed by sandwich-technique: 'Sandwich-plus-technique'

The incidence of parastomal hernias after a permanent stoma is between 50% and 80% depending on the type of stoma, the definition of the hernia (clinical or radiological), and the length of the follow-up. Surgical therapy is complex and involves several techniques with different recurrence rates. We present three cases where we have closed the hernia gap with continuous, non-resorbable, self-retaining sutures with subsequent use of the sandwich technique (’Sandwich-plus-technique’). There were pronounced parastomal hernias in three female patients (mean age was 72 years and the range was 63–78 years) with permanent colostomata. After laparoscopic adhesiolysis, the closure of the hernia defect was completed with ongoing, barbed non-resorbable 1-0 sutures (polybutester) followed by the sandwich technique. There were no intraoperative complications and currently no clinical or radiological evidence for recurrences of the parastomal hernia. Closure of the hernia gap leads to the additional reconstruction of the lateral abdominal wall, resulting in a larger contact surface for integration of the keyhole mesh and thus prior to implantation of the Sugarbaker mesh. The laparoscopic augmentation of large parastomal hernias using the ‘Sandwich-plus-technique’ is technically complex but achieves very good results in our case series. Further studies and long-term results should prove that the low recurrence rate of the sandwich technique can be further reduced.

Clinical outcomes after parastomal hernia repair with a polyester monofilament composite mesh: a cohort study of 79 consecutive patients

PURPOSE

Different techniques and mesh materials are used in parastomal hernia repair with recently reported recurrence rates ranging from 10 to 28%. The aim of this cohort study was to examine the risk of recurrence and chronic pain after Sugarbaker or keyhole parastomal hernia repair with intraperitoneal placement of a polyester monofilament macroporous composite mesh.

METHODS

Data on all patients undergoing parastomal hernia repair with Parietex™ Composite Parastomal Mesh at our institution during a 4-year period were examined. Patients with urostomy were excluded. A team of three experienced surgeons performed all repairs. Follow-up including physical examination was done after 10 days, 6 and 12 months, and hereafter as annual structured telephone interviews. Patients suspected of hernia recurrence were offered computed tomography scan. Chronic pain was defined as pain requiring out-patient visit(s) and/or regular use of analgesics.

RESULTS

79 patients (Sugarbaker, n = 69; keyhole, n = 10) were included. Of those, 72 procedures were performed laparoscopically and seven by open technique. Two patients were reoperated within 30 days with removal of the mesh. In total, seven (9%) patients had parastomal hernia recurrence (reoperation, n = 3; conservative management, n = 4) during follow-up of median 12 months (range 0-49 months). In univariable logistic analyses, type of stoma was associated with recurrence (ileostomy 28% vs colostomy 3%, p = 0.007). Three patients (4%) reported chronic pain.

CONCLUSION

In this study, we found low rates of recurrence and chronic pain following parastomal hernia repair using intraperitoneal reinforcement with a polyester monofilament composite mesh.

Synthetic vs biologic mesh for the repair and prevention of parastomal hernia

AIM

To outline current evidence regarding prevention and treatment of parastomal hernia and to compare use of synthetic and biologic mesh.

METHODS

Relevant databases were searched for studies reporting hernia recurrence, wound and mesh infection, other complications, surgical techniques and mortality. Weighted pooled proportions (95%CI) were calculated using StatsDirect. Heterogeneity concerning outcome measures was determined using Cochran’s Q test and was quantified using I². Random and fixed effects models were used. Meta-analysis was performed with Review Manager software with the statistical significance set at P ≤ 0.05.

RESULTS

Forty-four studies were included: 5 reporting biologic mesh repairs; 21, synthetic mesh repairs; and 18, prophylactic mesh repairs. Most of the studies were retrospective cohorts of low to moderate quality. The hernia recurrence rate was higher after undergoing biologic compared to synthetic mesh repair (24.0% vs 15.1%, P = 0.01). No significant difference was found concerning wound and mesh infection (5.6% vs 2.8%; 0% vs 3.1%). Open and laparoscopic techniques were comparable regarding recurrences and infections. Prophylactic mesh placement reduced the occurrence of a parastomal hernia (OR = 0.20, P < 0.0006) without increasing wound infection [7.8% vs 8.2% (OR = 1.04, P = 0.91)] and without differences between the mesh types.

CONCLUSION

There is no superiority of biologic over synthetic mesh for parastomal hernia repair. Prophylactic mesh placement during the initial surgery significantly reduces parastomal hernia occurrence regardless of the mesh type.

Parastomal Hernia Repair with Intraperitoneal Mesh

Purpose

Parastomal hernia is a common complication following a stoma and may cause leakage or incarceration. No optimal treatment has been established, and existing methods using mesh repair are associated with high recurrence rates and a considerable risk for short- and long-term complications including death. A double-layer intraperitoneal on-lay mesh (IPOM), the Parastomal Hernia Patch (BARD™), consisting of ePTFE and polypropylene, has been developed and tailored to avoid recurrence. To evaluate the safety of and recurrence rate using this mesh, a nonrandomised prospective multicentre study was performed.

Method

Fifty patients requiring surgery for parastomal hernia were enrolled. Clinical examination and CT scan prior to surgery were performed. All patients were operated on using the Parastomal Hernia Patch (BARD). Postoperative follow-up at one month and one year was scheduled to detect complications and hernia recurrence.

Results

The postoperative complication rate at one month was 15/50 (30%). The parastomal hernia recurrence rate at one year was 11/50 (22%). The reoperation rate at one month was 7/50 (14%), and further 5/50 (10%) patients were reoperated on during the following eleven months.

The use of a composite synthetic mesh in the vicinity of bowel - For repair and prophylaxis of parastomal hernias. Does it increase the risk of short term infective complications?

AIMS

The use of synthetic meshes in potentially infected operative fields such as in the vicinity of large bowel, is controversial. This study describes our experience with the use of a synthetic composite mesh for prophylaxis and repair of parastomal hernias.

METHODS

Data were collected retrospectively over a 7-year period from 2008 to 2015. An IPOM (DynaMesh™) was used either during the formation of the stoma to reinforce the abdominal wall around the stoma or during the surgical repair of existing parastomal hernias, using keyhole or sandwich technique. Majority of meshes were placed laparoscopically. Clinical data and outcomes any stoma wound complications were collected.

RESULTS

Forty seven patients were included with a male to female ratio of 34:13. Median age was 66 years (38-91 years) with median follow-up of 17 months (3-73 months). Twenty seven patients had a prophylactic mesh placement (PMP) around colostomy after resection of colorectal cancer. None of these patients had any wound complications. Twenty patients had repair of parastomal hernias (RPH). One patient (1/20) in this group had a superficial wound infection around the stoma site and underwent an incision and drainage. One patient developed seroma and one had parastomal wound haematoma.

CONCLUSIONS

The use of a composite synthetic mesh using a laparoscopic IPOM technique for the prophylaxis and treatment of parastomal hernias, even in a clean contaminated surgical field, is safe and feasible.

Preventing parastomal hernias with systematic intraperitoneal specifically designed mesh

BACKGROUND

Parastomal hernia is a very common complication after stoma formation. Current surgical techniques for repairing parastomal hernia have unsatisfactory results. We aim to assess our preliminary experience with prophylactic mesh placement at the time of stoma formation.

METHODS

Data were prospectively recorded. A specifically designed mesh made of polyvinyl fluoride with central conduit (Dynamesh IPST®) was fixed using an intra-peritoneal onlay technique. Safety was evaluated by means of surgical data and frequency of mesh-related complications, efficacy by the rate of parastomal hernias.

RESULTS

Thirty-four patients were included in the study. Three of them died before a year of follow up (not related to the stoma), so they were excluded. The other 31 patients (11 women and 20 men) were prospectively followed up after different pathologies resulting in a permanent colostomy. Twelve months after surgery CT-Scan imaging revealed two (6.4%) parastomal hernias, one of them already clinically suspected. During the follow up, 29% of the patients (n = 9) developed another type of hernia (incisional, inguinal or both). In five patients (16.1%) a light stomal retraction of the otherwise slightly prominent ostomy was observed. Median clinical follow-up was 17.5 months (range 12-34).

CONCLUSION

Prophylactic parastomal mesh placement might be a safe and effective procedure with a potential to reduce the risk of parastomal hernia. Routine use of this technique should be further analysed.

Prophylactic mesh placement for the PREvention of paraSTOmal hernias: The PRESTO systematic review and meta-analysis

Background

Parastomal hernia (PH) is the most common complication after ostomy formation. Prophylactic mesh placement may be effective in reducing the rate of PH at the stoma site. The aims of this systematic review were to summarize the evidence with regard to the safety and effectiveness in comparison with the standard procedure without mesh placement and to identify important risk constellations.

Method

A systematic literature search was performed in PubMed, EMBASE and the Cochrane library with no language or date restrictions. Randomized (RCTs) and non-randomized controlled trials (nRCTs) were included. The main outcomes of interest were PH (primary outcome) rate and stoma-related complications (secondary outcomes) such as stenosis or fistula. Statistical analysis included meta-analyses of pooled data and subgroup analyses.

Results

Eleven trials (eight RCTs; three nRCTs) with a total of 755 patients were included. PH rate varied from 0% to 59% in the intervention and from 20% to 94% in the control group. RCTs showed a significant reduction of PH rate in the mesh group (OR 0.24; 95% CI 0.10 to 0.58, p = 0.034), whereas included nRCTs did not. No significant differences were observed in postoperative complication rates. Subgroup analyses showed superiority of non-absorbable meshes and sublay mesh positioning in open surgery.

Conclusion

Prophylactic mesh placement is safe and reduces PH rate. A recommendation for prophylactic non-absorbable meshes in a sublay position can be made for patients undergoing open colorectal operations with end-ostomies. Further research endeavors should focus on patient-oriented outcomes, not only PH rate, with respect to tailored treatment in specific patient populations.

Laparoscopic repair of parastomal hernia

Parastomal hernia is one of the most common long-term complications after abdominal ostomy. Surgical treatment for parastomal hernia is the only cure but a fairly difficult field because of the problems of infection, effects, complications and recurrence. Laparoscopic repair operations are good choices for Parastomal hernia because of their mini-invasive nature and confirmed effects. There are several major laparoscopic procedures for parastomal hernioplasty. The indications, technical details and complications of them will be introduced and discussed in this article.

Changes in the Surgical Management of Parastomal Hernias Over 15 Years: Results of 135 Cases

BACKGROUND

Over the years, various open and laparoscopic approaches toward the repair of parastomal hernias (PSH) have been described. The variety of published techniques itself can be seen as an indicator for the often low level of satisfaction reached with the surgical procedures.

METHODS

From January 1999 to January 2014, we assessed all cases of PSH repair performed at the three participating surgical departments in a retrospective analysis. The results were evaluated with regard to different surgical techniques focusing on complications and recurrences.

RESULTS

One hundred and thirty-five individuals could be included in the analysis. They were operated on with eight different surgical techniques. Laparoscopic procedures were carried out in 46.7 % (63/135) of the cases. Median follow-up was 54 months (12-146 months). We found 44 cases of recurrence (32.6 %) and 24 (17.8 %) of the patients experienced perioperative complications and 12 of them needed to return to theater. Fourteen of the 135 patients (10.4 %) were operated as emergency cases which were associated with a mortality of 28.6 % (4/14). In case of elective PSH repair, no mortality occured.

CONCLUSION

The results achieved by direct suture or the use of incised flat meshes for the repair of PSH were poor with these procedures having unacceptably high recurrence rates. With regard to the latter ostomy revision through three-dimensional funnel-shaped meshes and the laparoscopic sandwich technique showed the best results. Emergency procedures were linked to a dramatic increase in morbidity and mortality (p < 0.001).

Long-term assessment of parastomal hernia prevention by intra-peritoneal mesh reinforcement according to the modified Sugarbaker technique

BACKGROUND

Parastomal hernia (PSH) is a very frequent complication after creation of a permanent colostomy. The aim of that study is to assess the safety and the long-term efficacy of an intra-peritoneal onlay mesh (IPOM) positioned at the time of primary stoma formation to prevent PSH occurrence.

MATERIALS AND METHODS

That multicentre prospective study concerned 29 consecutive patients operated for cancer of the low rectum between 2008 and 2014. There were 14 men and 15 women with a median age of 73 years (range 39-88) and a BMI of 28 (range 21-43). All the patients had potentially curative abdominoperineal excision associated with IPOM reinforcement of the abdominal wall with a round non-slit composite mesh centred on the stoma site and covering the lateralized colon according to the modified Sugarbaker technique. The major outcomes analysed were operative time, complications related to mesh and PSH incidence. Patients were evaluated at 6-month intervals for the first 2 years and thereafter annually with physical examination and CT scan control. For PSH evaluation, we used the classification of Moreno-Matias.

RESULTS

Surgery was performed by laparoscopy in 24 patients and by laparotomy in 5; 17 had a trans-peritoneal colostomy and 12 an extra-peritoneal colostomy. The median size of the mesh was 15 cm (range 12-20), the operative time 225 min. (range 123-311) and the specific time for mesh placement 15 min. (range 10-30). With a median follow-up of 48 months (range 6-88), no mesh infection or complication requiring mesh removal were recorded. No patient developed a true PSH; two of them had a type Ia PSH (only containing the bowel forming the colostomy with a sac < 5 cm) and were totally asymptomatic.

CONCLUSION

In our series, the incidence of PSH was 7 % and no specific mesh-related complication was noted. Prophylactic mesh reinforcement according to the modified Sugarbaker is an effective technique that addresses the issues related to the occurrence of PSH.

Single-port parastomal hernia repair by using 3-D textile implants

Background:

Parastomal hernias (PSHs) are a frequent complication and remain a surgical challenge. We present a new option for single-port PSH repair with equilateral stoma relocation using preshaped, prosthetic 3-dimensional implants and flat mesh insertion in intraperitoneal onlay placement for additional augmentation of the abdominal wall.

Methods:

We describe our novel technique in detail and performed an analysis of prospectively collected data from patients who underwent single-port PSH repair, focusing on feasibility, conversions, and complications.

Results:

From September 2013 to January 2014, 9 patients with symptomatic PSHs were included. Two conversions to reduced-port laparoscopy using a second 3-mm trocar were required because of difficult adhesiolysis, dissection, and reduction of the hernia sac content. No major intra- or postoperative complications or reoperations were encountered. One patient incurred a peristomal wound healing defect that could be treated conservatively.

Conclusion:

We found that single-port PSH repair using preshaped, elastic 3-dimensional devices and additional flat mesh repair of the abdominal wall is feasible, safe, and beneficial, relating to optimal coverage of unstable stoma edges with wide overlap to all sides and simultaneous augmentation of the midline in the IPOM technique. The stoma relocation enables prolapse treatment and prevention. The features of a modular and rotatable multichannel port system offer benefits in clear dissection ongoing from a single port. Long-term follow-up data on an adequate number of patients are awaited to examine efficacy.

Parastomal hernia repair with the Sugarbaker technique using e-PTFE mesh

PURPOSES

Although surgery is commonly used to treat parastomal hernia, it is very difficult and has shown poor results. Recently, repair with prosthetic materials has been thought to be a more promising method.

METHODS

The Sugarbaker technique with e-PTFE mesh (Dualmesh^®) performed via open surgery was adopted for seven patients with parastomal hernia. Two of them were recurrent cases. Three of the patients experienced incarceration of the intestine and recovered conservatively before surgery. The median age of the patients at the parastomal hernia repair was 77.6 years old (range 37.7-84.7).

RESULTS

The median operative time was 211 min (range 147-256). The median hernia size was 28 cm² (range 7.5-60 cm²). The median amount of blood loss during the operation was 158 g (range 0-370 g). Surgical site infection was not observed. The postoperative median hospital stay was 17 days (range 13-40) and the median follow-up was 2.4 years (range 1.0-3.7). During the follow-up period, we did not observe recurrence or readmission.

CONCLUSIONS

The surgical results were satisfactory with minimal morbidity and no recurrences. The Sugarbaker technique for parastomal repair using e-PTFE mesh may be suitable as a standard method for treating parastomal hernia.

Modified laparoscopic Sugarbaker repair decreases recurrence rates of parastomal hernia

BACKGROUND

Parastomal hernia (PH) is a frequent complication of stoma formation, and recurrence after repair is common. A laparoscopic modified Sugarbaker technique (SB) may decrease the recurrence of PH compared with other methods.

METHODS

A retrospective review, approved by the institutional review board, of patients who underwent PH repair between 2004 and 2014 was performed. Demographics, factors for ostomy formation, hernia risk factors, intraoperative and postoperative information, and recurrence data were compared among SB and other techniques. Time to recurrence was compared between SB versus other techniques with the Kaplan-Meier method and adjusted Cox proportional hazards regression modeling.

RESULTS

Sixty-two PH repairs were performed: 39 (61%) paraileostomy and 23 (39%) paracolostomy. Repairs included 25 laparoscopic modified SB and 37 from other techniques. There was no difference in demographics. Postoperative complication rate was lesser in SB versus all other groups (40% vs 76%, P = .02). Recurrence rates were lesser for SB versus all others (16% vs 60%, P < .001). Follow-up was similar among all groups. After adjustment, SB was found to be protective of recurrences (hazard ratio = .28, 95% confidence interval = 0.09-0.82).

CONCLUSION

A laparoscopic modified SB technique provides decreased rates of recurrence and postoperative complications compared with other approaches.

Current state of laparoscopic parastomal hernia repair: A meta-analysis

AIM: To evaluate the efficacy and safety of the laparoscopic approaches for parastomal hernia repair reported in the literature.

METHODS: A systematic review of PubMed and MEDLINE databases was conducted using various combination of the following keywords: stoma repair, laparoscopic, parastomal, and hernia. Case reports, studies with less than 5 patients, and articles not written in English were excluded. Eligible studies were further scrutinized with the 2011 levels of evidence from the Oxford Centre for Evidence-Based Medicine. Two authors reviewed and analyzed each study. If there was any discrepancy between scores, the study in question was referred to another author. A meta -analysis was performed using both random and fixed-effect models. Publication bias was evaluated using Begg’s funnel plot and Egger’s regression test. The primary outcome analyzed was recurrence of parastomal hernia. Secondary outcomes were mesh infection, surgical site infection, obstruction requiring reoperation, death, and other complications. Studies were grouped by operative technique where indicated. Except for recurrence, most postoperative morbidities were reported for the overall cohort and not by approach so they were analyzed across approach.

RESULTS: Fifteen articles with a total of 469 patients were deemed eligible for review. Most postoperative morbidities were reported for the overall cohort, and not by approach. The overall postoperative morbidity rate was 1.8% (95%CI: 0.8-3.2), and there was no difference between techniques. The most common postoperative complication was surgical site infection, which was seen in 3.8% (95%CI: 2.3-5.7). Infected mesh was observed in 1.7% (95%CI: 0.7-3.1), and obstruction requiring reoperation also occurred in 1.7% (95%CI: 0.7-3.0). Other complications such as ileus, pneumonia, or urinary tract infection were noted in 16.6% (95%CI: 11.9-22.1). Eighty-one recurrences were reported overall for a recurrence rate of 17.4% (95%CI: 9.5-26.9). The recurrence rate was 10.2% (95%CI: 3.9-19.0) for the modified laparoscopic Sugarbaker approach, whereas the recurrence rate was 27.9% (95%CI: 12.3-46.9) for the keyhole approach. There were no intraoperative mortalities reported and six mortalities during the postoperative course.

CONCLUSION: Laparoscopic intraperitoneal mesh repair is safe and effective for treating parastomal hernia. A modified Sugarbaker approach appears to provide the best outcomes.

Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines [corrected]

BACKGROUND

The Executive board of the Italian Society for Endoscopic Surgery (SICE) promoted an update of the first evidence-based Italian Consensus Conference Guidelines 2010 because a large amount of literature has been published in the last 4 years about the topics examined and new relevant issues.

METHODS

The scientific committee selected the topics to be addressed: indications to surgical treatment including special conditions (obesity, cirrhosis, diastasis recti abdominis, acute presentation); safety and outcome of intraperitoneal meshes (synthetic and biologic); fixing devices (absorbable/non-absorbable); abdominal border and parastomal hernia; intraoperative and perioperative complications; and recurrent ventral/incisional hernia. All the recommendations are the result of a careful and complete literature review examined with autonomous judgment by the entire panel. The process was supervised by experts in methodology and epidemiology from the most qualified Italian institution. Two external reviewers were designed by the EAES and EHS to guarantee the most objective, transparent, and reliable work. The Oxford hierarchy (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence") was used by the panel to grade clinical outcomes according to levels of evidence. The recommendations were based on the grading system suggested by the GRADE working group.

RESULTS AND CONCLUSIONS

The availability of recent level 1 evidence (a meta-analysis of 10 RCTs) allowed to recommend that not only laparoscopic repair is an acceptable alternative to the open repair, but also it is advantageous in terms of shorter hospital stay and wound infection rate. This conclusion appears to be extremely relevant in a clinical setting. Indications about specific conditions could also be issued: laparoscopy is recommended for the treatment of recurrent ventral hernias and obese patients, while it is a potential option for compensated cirrhotic and childbearing-age female patients. Many relevant and controversial topics were thoroughly examined by this consensus conference for the first time. Among them are the issue of safety of the intraperitoneal mesh placement, traditionally considered a major drawback of the laparoscopic technique, the role for the biologic meshes, and various aspects of the laparoscopic approach for particular locations of the defect such as the abdominal border or parastomal hernias.

Prevention of parastomal hernias with 3D funnel meshes in intraperitoneal onlay position by placement during initial stoma formation

PURPOSE

In patients with terminal ostomies, parastomal hernias (PSHs) occur on a frequent basis. They are commonly associated with various degrees of complaints and occasionally lead to life-threatening complications. Various strategies and measures have been tested and evaluated, but to date there is a lack of published evidence with regard to the best surgical technique for the prevention of PSH development.

METHODS

We conducted a retrospective analysis of prospectively collected data of eighty patients, who underwent elective permanent ostomy formation between 2009 and 2014 by means of prophylactic implantation of a three-dimensional (3D) funnel mesh in intraperitoneal onlay (IPOM) position.

RESULTS

PSH developed in three patients (3.75%). No mesh-related complications were encountered and none of the implants had to be removed. Ostomy-related complications had to be noted in seven (8.75%) cases. No manifestation of ostomy prolapse occurred. Follow-up time was a median 21 (range 3-47) months.

CONCLUSION

The prophylactical implantation of a specially shaped, 3D mesh implant in IPOM technique during initial formation of a terminal enterostomy is safe, highly efficient and comparatively easy to perform. As opposed to what can be achieved with flat or keyhole meshes, the inner boundary areas of the ostomy itself can be well covered and protected from the surging viscera with the 3D implants. At the same time, the vertical, tunnel-shaped part of the mesh provides sufficient protection from an ostomy prolapse. Further studies will be needed to compare the efficacy of various known approaches to PSH prevention.

New minimally invasive technique of parastomal hernia repair - methods and review

INTRODUCTION

Parastomal hernia is described as the most common complication in patients with ostomy. It is reported that its incidence varies from 3% to 39% for colostomies and 0 to 6% for ileostomies. Surgical repair remains the treatment of choice. There are three types of surgical treatment - fascial repair, stoma relocation and repair using prosthetic mesh via a laparoscopic or open approach. Recently there have been several meta-analyses and systematic reviews aiming to compare the results of surgical treatment, and the authors agreed that the quality of evidence precludes firm conclusions.

AIM

To describe the novel concept of parastomal hernia repair - HyPER/SPHR technique (hybrid parastomal endoscopic re-do/Szczepkowski parastomal hernia repair) and its early results in 12 consecutive cases.

MATERIAL AND METHODS

Twelve consecutive patients were operated on due to parastomal hernia using the new HyPER hybrid technique between June 2013 and May 2014. The patients' condition was evaluated during the perioperative period, 6 weeks and then every 3 months after surgery.

RESULTS

After 6 weeks of follow-up we have not observed any mesh-related complications. All 12 patients were examined 3 months and 6 months after repair surgery for evaluation. No recurrence, stoma site infection or stoma-related problems were found. None of the patients complained of pain and none of them needed to be hospitalized again. Reported quality of life on a 0-10 scale after 6 weeks of follow-up was 8 (range: 7-10).

CONCLUSIONS

The HyPER procedure for treatment of parastomal hernias proposed by the authors is a safe and feasible surgical technique with a high patient satisfaction rate and a low number of complications. The hybrid procedure seems to be a promising method for parastomal hernia repair.

Repair of complex parastomal hernias

Development of parastomal hernias (PH) is very common after stoma formation and carries a risk of subsequent bowel incarceration, obstruction and strangulation. The management of PH remains a challenge for the colorectal surgeon, and there are currently no standardized guidelines for the treatment of PH. Even more difficult is the management of complex parastomal hernias (CPH). We conducted a review of the literature to identify recent developments in the treatment of CPH, including analysis of the use of synthetic and biologic mesh prostheses, method of mesh placement and surgical approach.

Parastomal hernia: a growing problem with new solutions

Parastomal hernia is one of the most common complications following stoma creation and its prevalence is only expected to increase. It often leads to a decrease in the quality of life for patients due to discomfort, pain, frequent ostomy appliance leakage, or peristomal skin irritation and can result in significantly increased healthcare costs. Surgical technique for parastomal hernia repair has evolved significantly over the past two decades with the introduction of new types of mesh and laparoscopic procedures. The use of prophylactic mesh in high-risk patients at the time of stoma creation has gained attention in lieu of several promising studies that have emerged in the recent days. This review will attempt to demonstrate the burden that parastomal hernias present to patients, surgeons, and the healthcare system and also provide an overview of the current management and surgical techniques at both preventing and treating parastomal hernias.

Parastomal hernia repair and reinforcement: the role of biologic and synthetic materials

Parastomal hernia is a prevalent problem and treatment can pose difficulties due to significant rates of recurrence and morbidities of the repair. The current standard of care is to perform parastomal hernia repair with mesh whenever possible. There exist multiple options for mesh reinforcement (biologic and synthetic) as well as surgical techniques, to include type of repair (keyhole and Sugarbaker) and position of mesh placement (onlay, sublay, or intraperitoneal). The sublay and intraperitoneal positions have been shown to be superior with a lower incidence of recurrence. This procedure may be performed open or laparoscopically, both having similar recurrence and morbidity results. Prophylactic mesh placement at the time of stoma formation has been shown to significantly decrease the rates of parastomal hernia formation.

Parastomal hernia repair with a 3-D mesh device and additional flat mesh repair of the abdominal wall

PURPOSE

Parastomal hernias (PSHs) have been a major clinical problem. The aim of this study was to evaluate a new method of PSH repair in combination with an additional flat mesh reinforcement of the abdominal wall.

METHODS

In a pilot case series, seven patients suffering from complex PSHs (≥5 cm diameter and/or recurrence) underwent surgery and were treated by intraperitoneal onlay technique (IPOM) with a synthetic 3-D funnel-shaped mesh implant. The demographics, perioperative, and follow-up data are presented in this report.

RESULTS

The surgical strategy varied between purely laparoscopic (n = 1), laparoscopically assisted (hybrid n = 3), or open techniques (n = 3) using original or suture-reconstructed mesh devices. The funnel mesh implantations in IPOM technique were combined with attached flat meshes in the appropriate position of the abdominal wall. No procedure-related complications occurred. The mean length of hospital stay was 12 days and the mean operating time was 171 min. No recurrence of PSH or incisional hernias was observed during a mean follow-up period of 12.3 months (range from 7 to 22).

CONCLUSION

The use of a 3-D mesh implant has so far shown to be a promising option in the treatment of primary and recurrent PSHs. Its use proved to be reasonable in both laparoscopic and open IPOM technique. PSHs were preferably repaired using the original, unmodified implant, but when we also found it safe to incise, place and then suture the mesh around the pre-existing ostomy.

[Median incisional hernias and coexisting parastomal hernias : new surgical strategies and an algorithm for simultaneous repair]

The co-occurrence of incisional and parastomal hernias (PSH) remains a surgical challenge. Standardized treatment guidelines are missing, and the patients concerned require an individualized surgical approach. The laparoscopic techniques can be performed with incised and/or stoma-lateralizing flat meshes with intraperitoneal onlay placement. The purely laparoscopic and laparoscopic-assisted approaches with 3-D meshes offer advantages regarding the complete coverage of the edges of the stomal areas and the option of equilateral or contralateral stoma relocation in cases of PSH, which are difficult to handle due to scarring, adhesions, and large fascial defects > 5 cm with intestinal hernia sac contents. A relevant stoma prolapse can be relocated by tunnel-like preformed 3-D meshes and shortening the stoma bowel. The positive effect on prolapse prevention arises from the dome of the 3-D mesh, which is directed toward the abdominal cavity and tightly fits to the bowel. In cases of large incisional hernias (> 8-10 cm in width) or young patients with higher physical demands, an open abdominal wall reconstruction in sublay technique is required. Component separation techniques that enable tension-free ventral fascial closure should be preferred to mesh-supported defect bridging methods. The modified posterior component separation with transversus abdominis release (TAR) and the minimally invasive anterior component separation are superior to the original Ramirez technique with respect to wound morbidity. By using 3-D textile implants, which were specially designed for parastomal hernia prevention, the stoma can be brought out through the lateral abdominal wall without increased risk of parastomal hernia or prolapse development. An algorithm for surgical treatment, in consideration of the complexity of combined hernias, is introduced for the first time.